Provider Demographics
NPI:1437223781
Name:LEAK, EMILY YVONNE (MED,CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:EMILY
Middle Name:YVONNE
Last Name:LEAK
Suffix:
Gender:F
Credentials:MED,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 LEE ST # B
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3314
Mailing Address - Country:US
Mailing Address - Phone:770-830-8622
Mailing Address - Fax:770-832-9031
Practice Address - Street 1:121 LEE ST # B
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3314
Practice Address - Country:US
Practice Address - Phone:770-830-8622
Practice Address - Fax:770-832-9031
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP003772235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA150555980JMedicaid
GA150555980EMedicaid